What should I check in an elderly female patient presenting with generalized weakness?

Evaluation of Generalized Weakness in an Elderly Female

In an elderly female with generalized weakness, immediately assess vital signs (heart rate, blood pressure including orthostatic measurements), obtain a 12-lead ECG, check blood glucose, complete blood count, comprehensive metabolic panel (including electrolytes, renal and hepatic function), and perform a comprehensive medication review for myelotoxic or sedating agents. 1

Immediate Risk Stratification and Vital Signs

• Check heart rate and blood pressure immediately, with concern thresholds being heart rate >90 bpm and systolic blood pressure <110 mmHg, indicating potential hemodynamic instability requiring urgent intervention 1
• Obtain orthostatic blood pressure measurements (drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing) to detect volume depletion, autonomic dysfunction, or medication-related hypotension 1, 2
• Orthostatic hypotension is particularly important as elderly patients may present with atypical symptoms such as generalized weakness, stroke, syncope, or change in mental status rather than classic cardiovascular complaints 3

Essential Laboratory Workup

Core laboratory tests to obtain immediately:

• Blood glucose and hemoglobin A1c to evaluate for diabetes-related neuropathy and metabolic derangement 1
• Complete blood count with differential to assess for anemia, infection, or pancytopenia 1, 4
• Comprehensive metabolic panel including electrolytes (sodium, potassium, chloride, bicarbonate), renal function (BUN, creatinine), and hepatic function 1
• Phosphate, magnesium, potassium, and thiamine levels before any nutritional intervention, as deficiencies can cause profound weakness and refeeding syndrome carries up to 20% mortality risk 1, 4

Comprehensive Medication Review

This is a critical step that is often overlooked:

• Review all medications for myelotoxic agents including azathioprine, anticoagulants, antibiotics, and antihypertensives 1, 4
• Identify sedating medications such as psychotropics (benzodiazepines, antipsychotics, antidepressants), which impair emotional and physical drive and are major fall risk factors 1
• Assess for polypharmacy, as older adults with multiple conditions often require several medications that can interact or cause cumulative side effects 3

Focused History Elements

Distinguish the type and pattern of weakness:

• Differentiate true muscle weakness from fatigue, asthenia, or functional decline by asking the patient to perform specific tasks 1
• Determine the pattern: generalized versus focal, proximal versus distal, acute versus chronic onset 1
• Screen for falls in the past 12 months, as falls are frequently unreported and indicate multiple risk factors including medications, balance disorders, and visual deficits 1
• Ask specifically about postural symptoms (dizziness, lightheadedness upon standing), which may indicate orthostatic hypotension from cardiovascular disease or medications 2

Consider atypical presentations of serious conditions:

• Elderly patients may present with generalized weakness as the primary manifestation of acute coronary syndrome, rather than chest pain 3
• Cognitive impairment (present in 5% of 65-year-olds and 20% of 80-year-olds) may affect accuracy of symptom recall 3

Physical Examination Priorities

Perform these specific assessments:

• Gait assessment and "Get Up and Go" test: observe the patient stand from a chair without using arms, walk several paces, and return. Patients unable to perform this steadily require further evaluation and should not be discharged without reassessment 3, 1
• Cardiovascular examination including heart rate, rhythm, and auscultation for murmurs or arrhythmias 2
• Neurological examination including mental status, muscle strength testing, lower extremity peripheral nerve function, proprioception, reflexes, and tests of cortical, extrapyramidal, and cerebellar function 3
• Fundoscopic examination to look for papilledema indicating elevated intracranial pressure 1
• Visual acuity assessment, as visual impairment contributes to falls and functional decline 3

Frailty Assessment

• Assess frailty using the Clinical Frailty Score (1=very fit to 7=very frail) in all elderly patients with acute illness 1
• Evaluate functional status including activities of daily living (bathing, dressing, toileting, transferring, continence, feeding) and instrumental activities of daily living (managing finances, medications, transportation, shopping, cooking) 1
• Frailty symptoms include generalized weakness, exhaustion, slow gait, poor balance, decreased physical activity, cognitive impairment, and weight loss 5

Additional Testing Based on Clinical Suspicion

Obtain 12-lead ECG immediately to evaluate for arrhythmias (bradyarrhythmias, tachyarrhythmias, heart blocks) that can cause weakness and syncope 2

If infection is suspected:

• Perform urinalysis and urine culture immediately, as urinary tract infection is extremely common in elderly females and causes acute mental status changes and weakness 1

If inflammatory or rheumatologic cause is suspected:

• Obtain erythrocyte sedimentation rate and C-reactive protein levels 1

If neurologic deficit is identified:

• Neuroimaging (CT or MRI brain) is indicated for focal weakness or acute neurologic changes 6

Common Pitfalls to Avoid

• Do not dismiss generalized weakness as "normal aging" without thorough evaluation, as it is associated with poor outcomes and often represents serious underlying pathology 6, 5
• Do not overlook medication-induced causes, particularly in patients on multiple medications for chronic conditions 3, 1
• Do not miss orthostatic hypotension by failing to check standing blood pressures, especially in patients on antihypertensives or with cardiovascular disease 2
• Do not initiate aggressive nutritional support without monitoring for refeeding syndrome in malnourished patients 4